Revisional Bariatric Surgery in Israel: Findings from the Israeli Bariatric Surgery Registry.

BACKGROUND: Bariatric surgery (BS) is a proven sustainable approach for obesity, and its frequency is increasing worldwide. However, the frequency of revision surgery (RS) is also increasing. This study aimed to evaluate the RS rate in Israel and compare RS to primary surgery (PS). METHODS: Data were obtained from the Israeli Bariatric Surgery Registry. All patients aged > 18 years who underwent BS between June 2013 and December 2016 were considered for inclusion. Sociodemographic and clinical data were analyzed. RESULTS: PS was performed in 28,707 patients and RS was performed in 4026 patients. The mean body mass index values were 42.1 ± 5.0 and 41.3 ± 7.0 kg/m2 in the PS and RS groups, respectively. Hypertension, type 2 diabetes mellitus, dyslipidemia, and fatty liver were less frequent in the RS group than in the PS group. The percentage total weight loss (%TWL) values 6 months and 1 year postoperatively were 25.1 ± 8.1% and 30.5 ± 9.5%, respectively, in the PS group and 18.5 ± 8.9% and 23.12 ± 11.4%, respectively, in the RS group (P < 0.001). Complications were noted in 856 (3.5%) and 210 (6.2%) patients from the PS and RS groups, respectively. A multilinear regression model found that more weight loss was significantly associated with RS type (revision bypass vs. revision restrictive surgery). CONCLUSIONS: The RS rate is continuously increasing, and it should be tapered according to indications and feasibility. Our findings indicate that RS can be performed with acceptable complication rates and that restrictive surgery should be converted to bypass surgery to achieve acceptable weight loss with fewer complications.

Increased killer B cells in chronic HCV infection may lead to autoimmunity and increased viral load.

Regulatory B (Breg ) cells are characterized by various membrane markers and the secretion of different inhibitory cytokines. A new subset of Breg cells was identified as CD5hi Fas-ligand (FasL)hi . Their main reported role is to suppress anti-viral and anti-tumour immune responses, and, hence they have been dubbed 'killer' B cells. In this study, we aim to assess the role of these cells in chronic hepatitis C virus (HCV) infection, and determine if they contribute to the increased viral load and persistence of HCV and its related autoimmunity. (i) FasL expression on CD5hi B cells is increased significantly in HCV-infected patients compared to healthy individuals [28·06 ± 6·71 mean fluorescence intensity (MFI) ± standard error of the mean (s.e.m.), median = 27·9 versus 10·87 ± 3·97 MFI ± s.e.m., median = 10·3, respectively, P <  0·0001]. (ii) Killer B cells from HCV patients increased autologous CD4+ T cell apoptosis compared to the apoptosis in healthy individuals [39·17% ± 7·18% mean ± standard deviation (s.d.), median = 39·6 versus 25·92 ± 8·65%, mean ± s.d., median = 24·1%, P <  0·0001, respectively]. A similar increase was observed in CD8+ T cell apoptosis (54·67 ± 15·49% mean ± s.d., median = 57·3 versus 21·07% ± 7·4%, mean ± s.d., median = 20%, P = 0·0006, respectively). (iii) By neutralizing FasL with monoclonal anti-FasL antibodies, we have shown that the induction of apoptosis by killer B cells is FasL-dependent. (iv) Increased expression of FasL on CD5hi B cells is correlated positively with an increased viral load and the presence of anti-nuclear antibodies and rheumatoid factor in HCV. This is the first study in which killer B cells have been suggested to play a pathogenic role in HCV. They seem to be involved in HCV's ability to escape efficient immune responses.

Feasibility and Importance of Enteroscopy after Gastric Bypass.

BACKGROUND: Bariatric surgery has increased in popularity, with Roux-en-Y Gastric Bypass (RYGB) being one of the most frequently performed. This leads to many cases in which the stomach is removed from routine gastroscopy access, sometimes being a major source of concern. Performing enteroscopy in these patients is technically difficult. We present our experience with 24 cases in which the aim was to access the detached stomach. METHODS: Retrospective analysis on RYGB enteroscopy procedures aimed to access the detached stomach. Data recorded: demographic parameters, indication, gas insufflation, time to bypass stomach, total procedure and recovery times, and endoscopic and pathological findings. RESULTS: This study included 24 patients who underwent RYGB in the previous 3-36 months. Indications were chronic abdominal pain, refractory anemia, or unexplainable weight loss. Detached stomach was accessed in 79% of patients. Access time ranged from 25 to 55 min. Recovery time for all procedures was 86.66 min on average and shorter with CO2 insufflation (42.5 min). All detached stomachs showed macroscopic gastritis; four of them were Helicobacter pylori positive. Significant findings included three patients with jejunojejunostomy stenosis and one patient with a marginal gastrojejunal ulcer, which was later diagnosed with Signet ring cell carcinoma of the proximal anastomosis. CONCLUSIONS: We present the feasibility and importance of enteroscopy of the detached stomach and believe that this procedure should be performed more frequently. A high index of suspicion is needed for postoperative symptoms in order to exclude significant pathologies and reassure symptomatic patients that there is no abnormality in the bypassed stomach.

Sleeve Gastrectomy in Different Age Groups: a Comparative Study of 5-Year Outcomes.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has been used more frequently over the past 10 years. As the population ages, a larger number of older people will suffer from weight-related comorbidities, resulting in bariatric surgery becoming a dominant solution for improving health and quality of life. We assessed the long-term outcomes of LSG in elderly patients. METHODS: We conducted a retrospective chart review of patients who underwent LSG between January 2007 and August 2009. We subdivided 123 patients into <35 (n = 43), 35-55 (n = 59), and >55 (n = 21) age groups. RESULTS: The respective mean excess body mass index loss and excess weight loss were 42.5% ± 3.1% and 41.3% ± 12.3% for the <35 age group, 48.7% ± 4.1% and 45.6% ± 10.6% for the 35-55 age group, and 53.6% ± 4.6% and 52.1% ± 11.1% for the >55 age group. The follow-up compliance rates at the 5-year visit were 23.85, 31.11, and 47.61% for the <35, 35-55, and >55 age groups, respectively. The corresponding Bariatric Analysis and Reporting Outcome System scores were 3.7 ± 1.1, 4.0 ± 0.7, and 5.3 ± 1.3. The comorbidities of all the patients improved significantly, with a non-significant distribution between the three groups for each comorbidity. CONCLUSIONS: LSG is a useful tool for people who want to modify their eating habits and lose weight healthily. This study suggests that long-term weight loss, improvements in comorbidity, and compliance to follow-up are significant for patients >55 years old.

Over-the-Scope Clip (OTSC) System for Sleeve Gastrectomy Leaks.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is currently being widely accepted for its role in the treatment of morbid obesity. Staple-line leakage is one of the most reported complications found in 0.5-7 % of the population, in which the Over-the-Scope Clip (OTSC) (Ovesco Endoscopy, Tübingen, Germany), a novel device, is employed. We present our experience with this system in LSG leaks. METHODS: A retrospective analysis of prospectively collected data from patients with LSG leakage was performed, and these patients were treated with the OTSC system. Efficiency was defined as complete oral nutrition without any evidence of additional leakage. RESULTS: Overall, 26 patients underwent endoscopic OTSC treatment. The median age was 39 years (range 26-60), and 12 were male patients (46.15 %). The mean body mass index (BMI) was 42.89 kg/m(2), and 10 patients (38.46 %) came from a revisional bariatric procedure (SRVG or LAGB). Twenty-two patients (84.61 %) had upper staple-line leaks (near the GEJ), and the remaining 4 (15.38 %) had lower antral leaks. Number of endoscopy sessions ranged from 2 to 7 (median 3). There were five failures: 2 of them had an antral leak, and the remaining 3 had an upper staple-line leak. Twenty-one (80.76 %) leaks were successfully treated within 32 days' median time till complete oral nutrition was attained (range 14-70). CONCLUSIONS: The success rate was high with the OTSC system, and it is concluded to be a safe and effective treatment for LSG leaks.

False positive metaiodobenzylguanidine scan in a patient with a huge adrenocortical carcinoma.

We report a case of a 17-cm cortisol-secreting adrenocortical carcinoma in which [123I] metaiodobenzylguanidine (MIBG) scan showed accumulation of the isotope in the area of the tumor. Catecholamine levels were normal, and no chromaffin cells were found in histological examination of the tumor. A literature review of previously described cases of false positive MIBG scans in the adrenal region is offered. We conclude that MIBG scans might not be as specific as previously thought in differentiating pheochromocytoma from adrenocortical carcinoma. They should be performed only when clinical suspicion and abnormalities in catecholamines advocate the need.

[Listeria monocytogenes infections--ten years' experience].

7 cases of listeriosis were diagnosed here between 1988-1997 (6 in last 3 years), or 2.94/100,000 admissions. 2 elderly patients suffered from meningitis and 2 pregnant women presented with premature contractions, 1 of whom delivered a premature, infected baby. 2 other patients had fever and gastroenteritis. Listeria monocytogenes was isolated from blood in 4, CSF in 2 and the placenta in 1. It was isolated from those with bacterial meningitis. All patients recovered. Both increased awareness for prevention and better diagnosis are essential to reduce morbidity from this unusual pathogen.